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Presentation Goals 1. Describe the contextual forces that are triggering the call for a fundamental redesign of addiction treatment 2. Outline how service philosophies and practices are changing within Recovery- Oriented Systems of Care (ROSC)

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The Acute Care Model An encapsulated set of specialized service activities (assess, admit, treat, discharge, terminate the service relationship). An encapsulated set of specialized service activities (assess, admit, treat, discharge, terminate the service relationship). A professional expert drives the process. A professional expert drives the process. Services transpire over a short (and ever- shorter) period of time. Services transpire over a short (and ever- shorter) period of time. Individual/family/community are given impression at discharge (graduation) that recovery is now self-sustainable without ongoing professional assistance Individual/family/community are given impression at discharge (graduation) that recovery is now self-sustainable without ongoing professional assistance Source: White & McLellan, 2008, Counselor

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The Chronic Care Model Vision: medication-assisted metabolic stabilization for chronic opioid dependence as a foundation for long-term biopsychosocial recovery Model Deterioration: dosing with inadequate clinical & peer recovery support for psychosocial rehabilitation and & community re-integration Focus: what is subtracted/reduced (drug-related problems, crime, disease risk/transmission) from clients life rather than what is added (e.g., global personal/family health, productivity, life meaning/purpose, citizenship and service)

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Treatment Works Efficacy and effectiveness established via enhanced outcomes compared to no treatment or non-specialized treatment Lives of many individuals and families transformed through the medium of addiction treatment Effectiveness influenced by problem severity and complexity and recovery capital Source: Review in White, 2008 Monograph

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Existing Treatment Works, But… Inadequate quality (limited in scope of services and by methods lacking scientific support) Inadequate quality (limited in scope of services and by methods lacking scientific support) Passive rather than assertive linkage to communities of recovery & high attrition Passive rather than assertive linkage to communities of recovery & high attrition Inadequate post-treatment continuing care (received by only 10-20% of clients) Inadequate post-treatment continuing care (received by only 10-20% of clients) High rates (50%+) of post-treatment relapse (most within 90 days of discharge) & high re- admission rates (25-35% within one year) High rates (50%+) of post-treatment relapse (most within 90 days of discharge) & high re- admission rates (25-35% within one year)

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Existing Treatment Works, But… In the U.S, 64% of clients admitted to addiction treatment have one or more prior treatment episodes; 19% have 5 or more prior episodes In the U.S, 64% of clients admitted to addiction treatment have one or more prior treatment episodes; 19% have 5 or more prior episodes We are placing people in treatment whose design is incapable of generating sustainable recovery for many clients & then blaming the clients for that failure. We are placing people in treatment whose design is incapable of generating sustainable recovery for many clients & then blaming the clients for that failure. Sources: White, 2008 Monograph

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Toward a Model of Sustained Recovery Management (RM) Pre-recovery identification and engagement Pre-recovery identification and engagement Recovery initiation and stabilization Recovery initiation and stabilization Sustained support for recovery maintenance Sustained support for recovery maintenance Support for enhanced quality of personal/family life in long-term recovery Support for enhanced quality of personal/family life in long-term recovery --Emphasis on peer-based recovery support services and indigenous community support --Emphasis on peer-based recovery support services and indigenous community support Source: White, 2009, Journal of Substance Abuse Treatment

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Recovery Management: Emerging Elements Assertive approaches to continuing care (e.g., recovery checkups) for up to 5 years Assertive approaches to continuing care (e.g., recovery checkups) for up to 5 years Shift in helping role/relationship from expert to recovery consultant/partnership Shift in helping role/relationship from expert to recovery consultant/partnership Focus on building personal, family & community recovery capital, e.g. community development strategies Focus on building personal, family & community recovery capital, e.g. community development strategies Evaluation based on effects of multiple interventions on long-term addiction/treatment/recovery careers rather than immediate effects of single intervention Evaluation based on effects of multiple interventions on long-term addiction/treatment/recovery careers rather than immediate effects of single intervention

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Closing Thoughts 1. ROSC and RM represent not a refinement of modern addiction treatment, but a fundamental redesign of such treatment. 2. Overselling what existing treatment models can achieve to policy makers and the public risks a backlash and the revocation of addiction treatments probationary status as a cultural institution.

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Closing Thoughts 3. It will take years to transform addiction treatment into a model of sustained recovery support. 4. That process will require replicating what is already underway in many locations: aligning concepts, contexts (infrastructure, policies and system-wide relationships) and service practices to support long-term recovery for individuals and families.